Ab-interno canaloplasty (ABiC) with the iTrack (Ellex) microcatheter is one of the newer minimally invasive glaucoma surgery (MIGS) techniques. Preliminary studies and reports from surgeons using the procedure on patients with mild to moderate glaucoma show that the technique, in which the outflow channels of the eye are dilated and flushed out using a microscopic catheter, is not only very safe, but also notably reduces IOP and medication use.

Mark Gallardo, MD, of El Paso Eye Surgeons, TX, has been performing ABiC with iTrack for 3 years, and has achieved standout results. His latest patient, Peter Stewart, MD, medical director of LASERSIGHT in Australia, has set a new record: traveling almost 10,000 miles in search of this treatment. As an experienced ophthalmic surgeon himself, Dr. Stewart maintains that the results were worth every minute of his lengthy journey. Here, both doctors describe their experiences.

About ABiC

Mark J. Gallardo, MD: In recent decades, canaloplasty, in which a microcatheter is placed in Schlemm’s canal, facilitating viscodilation of the canal and distal outflow system, has become a favored method for surgically lowering IOP for some surgeons. However, among ophthalmic professionals, the word “canaloplasty” is often associated with the traditional ab-externo approach — an approach that requires large conjunctival and scleral dissections, which limits options for future conjunctival-based surgical procedures. Also, despite being a very elegant procedure, traditional ab-externo canaloplasty is considered to be a difficult and time-consuming procedure.

In contrast, ABiC with iTrack adopts a minimally invasive ab-interno approach, which was one of the features of the new procedure that caught Dr. Stewart’s attention. He was in the audience when I presented my data on the outcomes achieved with ABiC using a microcatheter versus traditional ab-externo canaloplasty in patients with mild to moderate glaucoma during the European Society of Cataract and Refractive Surgery (ESCRS) 2016 Congress. My findings show ABiC to be just as effective at reducing IOP and medication use as ab-externo canalopasty, but with the additional bonus of requiring no scleral incisions or tensioning suture.

In fact, ABiC with microcatheter opens up and viscodilates all sites involved in aqueous outflow, which means there is no need to pinpoint the blockage location and stent it. Instead, the illuminated iTrack microcatheter is inserted via a tiny (1.8 mm) corneal incision prior to viscodilation. This means that the natural outflow pathway is naturally restored with minimal tissue trauma and no foreign body left in the eye after surgery.

As a chronic glaucoma patient using topical medications that triggered ocular tissue irritation, ABiC’s effectiveness for reducing medication dependency was very appealing to Dr. Stewart. And the procedure’s low-risk, restorative approach convinced him to get in touch with me.

Peter Stewart, MD: I have two sisters and a brother, all of whom have glaucoma. When I was first diagnosed, the pressure in my right eye (the more severely affected eye) was 28 mmHg, and I was using two different glaucoma drugs in a combined drop. The main problem with relying on drops to manage my IOP was that I have blepharitis, so the drops made my eyes even sorer, and people commented on my red eyes all the time. I knew I was going to need a surgical intervention to reduce my dependency on eye drops.

As an ophthalmologist, I had heard about a new ab-interno MIGS procedure in passing, but as my clinic is tailored toward refractive surgery rather than glaucoma, I never listened all that closely when conversations about the new procedure arose.

However, when I heard Dr. Gallardo speak about ABiC with microcatheter, I was impressed. My lasting thoughts were: This is a procedure that doesn’t do any harm and leaves your eyes in a state where you’re still able to have conventional treatments thereafter, if need be.

After watching one of my sisters experience a problematic trabeculectomy, in which there was too much drainage, I decided I wanted to have a low-intervention procedure. And, after hearing about the benefits of ABiC, I instantly knew what I needed to do — and I wanted to do it as soon as possible. So, I flew to Los Angeles, took a connecting flight to El Paso, and underwent ABiC.

The Surgery

Dr. Gallardo: The biggest challenge posed by performing the procedure on Dr. Stewart was the distance he had traveled. Ordinarily, I perform ABiC on a patient’s first eye and ask him to return in 3 weeks for treatment on the second eye.

Given the impracticality of doing so in Dr. Stewart’s case, I had to operate on both eyes in a single procedure. However, he did extremely well. In fact, less than 24 hours later, he was back in the operating room with me — this time as a spectator, watching as I operated on another patient.

The speed with which Dr. Stewart was able to return to his normal activities after ABiC demonstrates how atraumatic the procedure really is, and how quickly patients can recover from it.

Post-Surgery: 4-month Progress Report

Dr. Gallardo: It has been about 4 months since Dr. Stewart’s surgery, and he has gone from being on daily Combigan (brimonidine tartrate/timolol maleate ophthalmic solution; Allergan) with an IOP in the mid-teens to being completely medication free, with his IOP maintained in the low teens. That’s a successful outcome.

Dr. Stewart: It has been 4 months since surgery, and I rarely think about my eyes at all. I’m completely off the eye drops, and I no longer have to endure the misery of sore eyes that get increasingly worse as the day progresses.

Despite the long journey to undergo the surgery in El Paso, I have absolutely no regrets. I wholeheartedly recommend ABiC with micro-catheter to any glaucoma patient who doesn’t like using their eye drops, because it is such a harmless procedure.

The only negative I experienced throughout the whole process was due to my unique situation of requiring both eyes to be operated on at the same time. It’s true that I had an uncomfortable night after having both eyes treated at once, but that discomfort was short lived, and I was in theatre the next day watching Dr. Gallardo operate with no pain or irritation. I am now a firm believer in ABiC and look forward to its growing acceptance in the Australian market. GP

Dr. Gallardo is a glaucoma specialist at El Paso Eye Surgeons in Texas.

Dr. Stewart is the director of surgery at LASERSIGHT, with multiple locations throughout Australia.